Lichtenstein Tension-Free Mesh Repair

Incision
The incision is placed about 1 cm above and parallel to the inguinal ligament,
beginning from the pubic tubercle and extending 5-6 cm laterally up to the
midinguinal point (see the images below). The subcutaneous fat is then opened along
the length of the incision, and careful hemostasis is achieved by ligating superficial
pudendal and superficial epigastric vessels.

Open inguinal hernia repair. Draping and incision.

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Open inguinal hernia repair. Skin incision.

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The Scarpa fascia is similarly opened along the length of the incision, down to the
external oblique aponeurosis, and the external inguinal ring and the lower border of
the inguinal ligament are visualized (see the images below). Below the inguinal
ligament, on the medial aspect, the deep fascia of the thigh is opened, the femoral
canal exposed, and a check made for any concomitant femoral hernia. Although the
risk is very low, routine exploration of the femoral canal is advised in the absence of
an inguinal hernia and in women. [5]

Open inguinal hernia repair. External oblique aponeurosis with external inguinal
ring.

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Open inguinal hernia repair. External oblique aponeurosis with external inguinal
ring.

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Division of external oblique aponeurosis and exposure of inguinal canal

The external oblique aponeurosis is then opened along the line of incision, starting
from the external ring and extending laterally for up to 5 cm (see the image below).
The ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this
procedure.

Open inguinal hernia repair. Division of external oblique aponeurosis.

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The superior and inferior flaps of the external oblique aponeurosis are gently freed
from the underlying contents of the inguinal canal and overturned and separated to
expose the cremaster with the cord structures, the ilioinguinal and iliohypogastric
nerves, the uppermost aponeurotic portion of the internal oblique muscle and
conjoined tendon, and the free lower border of the inguinal ligament (see the images
below). Wide separation of the two flaps provides ample space for placement and
fixation of mesh under vision while protecting the nerves.

Open inguinal hernia repair. Reflected part of inguinal ligament exposed for
fixing inferior edge of mesh.

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Open inguinal hernia repair. Inferior flap of external oblique aponeurosis

developed to expose inguinal ligament from pubic tubercle to midinguinal point.

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Open inguinal hernia repair. Superior flap of external oblique aponeurosis is

developed as high as possible to provide ample space for mesh placement.

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Dissection of spermatic cord

The spermatic cord, along with the cremaster, is then lifted up and separated from the
pubic bone for about 2 cm beyond the pubic tubercle to create space for extending the
mesh well beyond the pubic tubercle.
When lifting the cord, the surgeon must be sure to include the ilioinguinal nerve, the
genitofemoral nerve, and the spermatic vessels along with it. All of these structures
may then be encircled in a tape for ease of handling. The anatomic plane between the
cremaster and the aponeurotic tissue attached to the pubic bone is avascular, and cord
structures encircled in the tape can be separated from the floor of the inguinal canal
up to the internal ring. (See the images below.)

Open inguinal hernia repair. Avascular plane between posterior inguinal wall and
cord structures.

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Open inguinal hernia repair. Cord structures and hernia sac encircled by Penrose
drain.

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Open inguinal hernia repair. Lifting up cord with hernia sac medial to external
inguinal ring.

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Open inguinal hernia repair. Cord structures and hernia sac looped along with
ilioinguinal and genitofemoral nerves.
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A visible landmark for safeguarding the genitofemoral nerve is the external spermatic
vein, usually referred to as the “blue line.” If the blue line is kept with the spermatic
cord, the surgeon can be sure that the genital branch of the genitofemoral nerve,
which is always adjacent to this vein, is well protected. [54]
Identification and management of hernia sac
The cord structures and all of the nerves of the inguinal canal having been visualized,
the next step is to identify and isolate the hernia sac. The patient is asked to cough,
and the groin region is examined for the presence of an indirect hernia, a direct hernia,
a femoral hernia, a combined hernia, or a spigelian hernia.
A hernia sac can be managed by means of inversion, division, resection, or ligation.
Resection and ligation of a small hernia sac should not be performed unnecessarily,
because postoperative pain commonly results. However, the hernia sac must be well
separated from the internal ring before it is invaginated. The risk of recurrence is not
increased when a small or medium-sized indirect hernia sac is not ligated. [54] Excision
of an indirect inguinal hernia sac is associated with a lower risk of hernia recurrence
than is division or invagination. [55]
When the hernia sac is excised or divided, the proximal sac should never be left open;
doing so may lead to recurrence. The proximal sac is dissected free of cord structures
well above the internal ring, and a high ligation of the neck of the sac should be
performed.
The indirect hernia sac lies anterolateral to the cord structures and is visualized by
dividing the cremaster muscle longitudinally (see the image below). The cremaster
muscle should not be divided transversely or excised, because doing so may result in
low-lying testes and dysejaculation.

Open inguinal hernia repair. Cremaster muscle picked up to be incised

longitudinally between hemostats.

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The peritoneal sac is identified and separated from the spermatic vessels and the vas
deferens up to its neck (see the images below). A small or medium-sized hernia sac
may be isolated and inverted into the preperitoneal space without suture ligation. For
a voluminous scrotal hernia sac, no attempt should be made to dissect it completely
and excise it; such an attempt can result in ischemic orchitis. [5]

Open inguinal hernia repair. Hernia sac separated from cord structures.

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Open inguinal hernia repair. Indirect hernia sac dissected and being separated
from lipoma of cord and cord structures.

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Open inguinal hernia repair. Lipoma of cord dissected free and excised.
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Open inguinal hernia repair. Indirect hernia sac separated from cord structures in
midinguinal region toward neck of sac.

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Open inguinal hernia repair. Voluminous indirect hernia sac separated from cord
structures in midinguinal region up to neck of sac.

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The neck of a large hernia sac is transected at the midpoint of the inguinal canal (see
the first image below), and the proximal part is suture-ligated. A high ligation of the
proximal sac is recommended, and the stump is reduced deep underneath the internal
ring (see the second image below). The distal sac is left in place; however, the
anterior wall of the distal sac is incised to prevent postoperative hydrocele formation
(see the third image below).

Open inguinal hernia repair. Hernia sac being divided near neck.

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Open inguinal hernia repair. Contents of hernia sac reduced and proximal end to
be sutured closed.

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Open inguinal hernia repair. Anterior wall of distal sac incised to prevent
hydrocele formation.

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A direct inguinal hernia lies posteromedial to the cord structures. The direct hernia sac
is isolated and dissected free. Its contents are reduced, and the peritoneal sac is
inverted and maintained in position with a purse-string suture.
If a femoral hernia is suspected, the femoral ring should be evaluated by incising the
medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is
reduced and dealt with by inverting or ligating the neck of the sac. A spigelian hernia
is managed in a similar manner. A sliding hernia is simply dissected free and inverted
in the preperitoneal space.
Placement and fixation of mesh
A 7.5 × 15 cm piece of polypropylene mesh is commonly used for a Lichtenstein
hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to
conform to the patient’s anatomy. For a femoral hernia, the mesh is tailored so that it
has a triangular extension from its lower edge on its medial side.
To compensate for future shrinkage, the mesh should be wide enough to extend 3-4
cm beyond the boundary of the inguinal triangle. To compensate for increased intra-
abdominal pressure when the patient stands up, the mesh should be placed lax in the
posterior wall of the inguinal canal in such a way that it acquires a domelike wrinkle.
The first medialmost stitch fixes the mesh 2 cm medial to the pubic tubercle, where
the anterior rectus sheath inserts into the pubic bone (see the image below). Care
should be taken not to pass the needle through the periosteum of the bone or through
the pubic tubercle; this is one of the most common causes of chronic postoperative
pain.

Open inguinal hernia repair. First medialmost stitch in mesh, fixed about 2 cm
medial to pubic tubercle, where anterior rectus sheath inserts into pubis.

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The same suture is then used as a continuous suture to fix the lower edge of the mesh
to the free lower border of inguinal ligament up to a point just lateral to the internal
ring (see the images below). No more than four or five passes are required.

Open inguinal hernia repair. Same suture is utilized as continuous suture to fix
lower edge of mesh to reflected part of inguinal ligament up to internal ring.

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Open inguinal hernia repair. Fixation of lower edge of mesh.

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For a femoral hernia, the medial portion of the iliopubic tract is excised, and the
Cooper ligament is exposed. The lower triangular extension on the medial side of the
mesh is stitched to the Cooper ligament, and the suture is continued to fix the lower
edge of the mesh to the inguinal ligament, as above.
Next, a slit is made in the lateral end of the mesh to create a narrower lower tail (the
lower one third) and a wider upper tail (the upper two thirds). The slit extends up to a
point just medial to the internal inguinal ring (see the image below).

Open inguinal hernia repair. Lower edge of mesh sutured to inguinal ligament up
to internal inguinal ring. To accommodate cord structures, lateral end of mesh is
divided into wider upper (two thirds) tail and narrower lower (one third) tail.

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The upper tail is then passed underneath the cord in such a way as to position the
mesh posterior to the cord in the inguinal canal (see the image below), and the
spermatic cord is placed between the two tails of the mesh. The upper tail is then
crossed over the lower one, and the two tails are held in an artery forceps.

Open inguinal hernia repair. Wider upper tail of mesh is passed underneath cord,
and mesh is placed posteriorly in inguinal canal behind spermatic cord.

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With the mesh kept lax, its upper edge is then fixed to the rectus sheath and the
internal oblique aponeurosis with two or three interrupted nonabsorbable sutures (see
the first image below). On occasion, the iliohypogastric nerve is found to be in the
way of upper edge of the mesh. In such cases, the mesh may be split to accommodate
the nerve (see the second image below).

Open inguinal hernia repair. Fixation of upper edge of mesh.

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Open inguinal hernia repair. Slit made in mesh to accommodate iliohypogastric

nerve. Two interrupted sutures are taken under vision to fix upper edge of mesh while
safeguarding iliohypogastric nerve.

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The two tails are then tucked together and fixed to the inguinal ligament just lateral to
the internal ring, thus creating a new internal ring made of mesh (see the first image
below). The tails are trimmed 5 cm beyond the internal ring and placed underneath
the external oblique aponeurosis (see the second image below).

Open inguinal hernia repair. Upper tail is crossed over lower tail around
spermatic cord, thus creating internal ring. Lower edges of two tails are tucked
together to inguinal ligament just lateral to internal ring.

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Open inguinal hernia repair. Tails are then passed underneath external oblique
aponeurosis to give overlap of about 5 cm beyond internal ring.

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Suturing the mesh beyond the internal ring is unnecessary; doing so may cause injury
to the femoral nerve. Similarly, fixation of the tails of the mesh to the internal oblique
muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal nerve.
Trying to suture the two tails without crossing them or trimming the tails shorter than
5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring. [54]
If any of the nerves is injured or of doubtful integrity, it can be resected and its
proximal end ligated and buried within the fibers of the internal oblique muscle to
keep the stump of the nerve away from scarring.
In male patients, the testes should always be gently pulled back down to their normal
scrotal position after fixation of the mesh.
Closure
Spermatic cord layers are closed with fine sutures, with care taken to avoid damaging
the cord contents. Hemostasis is ensured in the inguinal canal, which is then closed by
suturing the two flaps of the external oblique aponeurosis (see the images below),
with care taken not to injure the underlying ilioinguinal nerve. Suturing is started
laterally and continued medially, where an adequate opening is left at the newly
created superficial inguinal ring so as not to occlude the emerging spermatic cord.
 Open inguinal hernia repair. External oblique aponeurosis sutured with 2-0
polypropylene.

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Open inguinal hernia repair. Closure of external oblique aponeurosis.

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Subcutaneous tissue is approximated with interrupted sutures to obliterate any dead

space, and the skin is approximated with sutures, clips, or adhesive strips (see the
images below). A subcuticular continuous stitch with 3-0 absorbable sutures obviates
any need for stitch or clip removal and provides better cosmetic results.

Open inguinal hernia repair. Subcutaneous tissue approximated with 3-0 plain
catgut.

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Open inguinal hernia repair. Skin approximated with 2-0 polypropylene

subcuticular suture.

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Open inguinal hernia repair. Skin closure.

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The operative site is cleaned and a sterile dressing applied. Local infiltration of a
long-acting anesthetic agent (eg, bupivacaine or ropivacaine) into the subcutaneous
tissue around the incision provides good immediate postoperative pain relief. A
bupivacaine-containing bioresorbable collagen implant is available for management
of pain after open inguinal hernia surgery. [56]
Other Approaches
Open inguinal hernia repairs other than Lichtenstein hernioplasty are
not merely of historical interest. Surgeons must know and understand
these repairs so that they can be carried out when they are
appropriate. Specifically, cases that involve a contaminated field (eg,
necrotic or perforated bowel secondary to hernial strangulation) are
not amenable to prosthetic repair. In such cases, either a primary
tissue repair or a biologic implant repair is necessary. [57, 31, 32]
Plug-and-patch repair
The plug-and-patch repair adds a polypropylene plug shaped as a
cone, which can be deployed into the internal ring after reduction of
an indirect sac. The plug then acts as a toggle bolt to reinforce the
defect.
Prolene Hernia System
The Prolene Hernia System (PHS) consists of an anterior oval
polypropylene mesh connected to a posterior circular component.
The posterior component is deployed in a bluntly created
preperitoneal space (see the first image below). The anterior portion
is then laid out with a cut made to recreate the internal ring (see the
second image below). The anterior portion is then sutured above to
the conjoined tendon and below to the shelving edge of the inguinal
ligament and is tucked behind the external oblique aponeurosis (see
the third image below).

Open inguinal hernia repair. Development of preperitoneal space.

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Open inguinal hernia repair. Deployment of Prolene Hernia

System (PHS).
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Open inguinal hernia repair. Final position of Prolene Hernia

System (PHS) mesh.
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McVay repair
In the McVay repair, the conjoined (transversus abdominis and
internal oblique) tendon is sutured to the Cooper ligament with
interrupted nonabsorbable sutures.
Bassini repair
The Bassini technique for inguinal hernia repair involves suturing the
transversalis fascia and the conjoined tendon to the inguinal ligament
behind the spermatic cord with monofilament nonabsorbable suture.
It also involves the so-called Tanner slide, which is a vertical relaxing
incision in the anterior rectus sheath intended to prevent tension.
Shouldice repair
The Shouldice technique is a four-layer inguinal hernia repair
performed with the patient under local anesthesia. The transversalis
fascia is incised from the internal ring laterally to the pubic tubercle
medially, and upper and lower flaps are created. These flaps are then
overlapped (double-breasted) with two layers of sutures.
The conjoined tendon is then sutured to the inguinal ligament, again
in two overlapping layers. This reinforces the posterior wall and
narrows the deep inguinal ring. The Shouldice repair is classically
done with a continuous suture of 32- to 34-gauge stainless steel wire,
but synthetic monofilaments (eg, polypropylene) can also be used.
The external oblique aponeurosis is then closed in a double-breasted
fashion in front of the spermatic cord.
Darn repair
A darn inguinal hernia repair is a pure-tissue tensionless technique
that is performed by placing a continuous suture between the
conjoined tendon and the inguinal ligament without approximating the
two structures.
Acellular dermal implant
Some reports describing the use of an acellular dermal implant (eg,
AlloDerm; LifeCell, Bridgewater, NJ) in cases where the surgical field
is contaminated have appeared in the literature, but long-term results
are not yet available. [30, 37]